Basic Information
| Provider Information | |||||||||
| NPI: | 1013384932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTIRE | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7234 HAMPSHIRE DR NE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524026904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193615462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 740 N 15TH AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | HIAWATHA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522332384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193983562 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 072841 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0074575 | 05 | IA | MEDICAID |